Women's Representation as Principal Investigators Among Pediatric Orthopaedic Clinical Trials: An Analysis of ClinicalTrials.Gov.

INTRODUCTION: Despite recent efforts to increase the participation of women in orthopaedic surgery, there remains a gender gap, particularly when compared with other medical specialties. Acting as a principal investigator (PI) in a clinical trial can give physicians notable exposure and national recognition, which can improve their chances of promotion and tenure. This study aims to assess the proportion of women serving as PIs in pediatric orthopaedic clinical trials, examine associated trial characteristics, and explore geographic distribution. METHODS: A cross-sectional analysis of clinical trials was conducted using data from the ClinicalTrials.gov registry. Specific search terms were used to identify pediatric orthopaedic trials. Data on trial characteristics, including phase, status, funding source, and intervention type, were collected. PI sex was determined using Genderize.io, an application program interface that predicts the sex of individuals based on their name, and the geographic distribution of women PIs was examined. RESULTS: From 2007 to 2022, women PIs increased from zero to 26.86%. The United States saw no significant increase (ß = 1.553; P = 0.125), but international trials did (ß = 2.845; P = 0.008). Women PIs led more active/completed trials and trials with behavioral/other interventions. Geographic analysis showed higher representation in North America (38.47%), especially the Northeast (28.17%) and West (25.35%). The United States had 28.74% women PIs, with California (15.49%) leading. CONCLUSION: Progress toward gender parity in pediatric orthopaedic research is evident; however, disparities still exist. Efforts to provide additional research opportunities for women in orthopaedics may be crucial in attracting and retaining diverse talent in the field. Targeted initiatives may have potential in achieving equal representation in orthopaedics.

Less common than expected: late displacement after minimally displaced pediatric lateral condyle fractures of the elbow.

The incidence of late displacement among pediatric lateral condyle fractures has been described as 1.3-26%. However, prior studies are limited by small cohort sizes. The aim of this study was to determine the rate of late displacement and delayed union among lateral condyle fractures following immobilization in a large cohort and to establish additional radiographic criteria to help surgeons choose between immobilization and operative fixation for minimally displaced fractures. We performed a dual-center retrospective study of patients with lateral condyle fractures between 1999 and 2020. Patient demographics, injury mechanism, time to orthopedic presentation, duration of cast immobilization, and complications following casting were recorded. There were 290 patients with lateral condyle fractures included. The initial management in 61% of patients (178/290) was nonoperative, of which four had delayed displacement at follow-up and two developed delayed union requiring surgery (failure in 6/178, 3.4%). The mean displacement on the anteroposterior view was 1.3 ±â€…1.1 mm and the lateral view was 0.50 ±â€…1.0 mm in the nonoperative cohort. In the operative cohort, the mean displacement on AP was 6.6 ±â€…5.4 mm and the lateral view was 5.3 ±â€…4.1 mm. Our analysis found the rate of late displacement in patients treated with immobilization was lower than previously reported (2.5%; 4/178). The mean displacement on the lateral film in the cast immobilization cohort was 0.5 mm, suggesting that necessitating near anatomic alignment on the lateral film to consider nonoperative management may lead to a lower incidence of late displacement than previously reported. Level of evidence: Level III, retrospective comparative study.

The Reliability of the Modified Fels Knee Skeletal Maturity System.

BACKGROUND: The recently described Modified Fels knee skeletal maturity system (mFels) has proven utility in prediction of ultimate lower extremity length in modern pediatric patients. mFels users evaluate chronological age, sex, and 7 anteroposterior knee radiographic parameters to produce a skeletal age estimate. We developed a free mobile application to minimize the learning curve of mFels radiographic parameter evaluation. We sought to identify the reliability of mFels for new users. METHODS: Five pediatric orthopaedic surgeons, 5 orthopaedic surgery residents, 3 pediatric orthopaedic nurse practitioners, and 5 medical students completely naïve to mFels each evaluated a set of 20 pediatric anteroposterior knee radiographs with the assistance of the (What's the Skeletal Maturity?) mobile application. They were not provided any guidance beyond the instructions and examples embedded in the app. The results of their radiographic evaluations and skeletal age estimates were compared with those of the mFels app developers. RESULTS: Averaging across participant groups, inter-rater reliability for each mFels parameter ranged from 0.73 to 0.91. Inter-rater reliability of skeletal age estimates was 0.98. Regardless of group, steady proficiency was reached by the seventh radiograph measured. CONCLUSIONS: mFels is a reliable means of skeletal maturity evaluation. No special instruction is necessary for first time users at any level to utilize the (What's the Skeletal Maturity?) mobile application, and proficiency in skeletal age estimation is obtained by the seventh radiograph. LEVEL OF EVIDENCE: Level II.

Interdisciplinary Orthopedic Management of Pediatric Patella Dislocation and Instability: An Educational Case Series.

Pediatric patellar instability and/or dislocation is a challenging diagnosis category that requires an interdisciplinary team consisting of orthopedic surgeons and physical therapists for optimized patient outcomes. This educational case series outlines core concepts for three patients with unique patellar dislocation presentations. Case 1 is a 16-year-old male who presented with a history of five knee traumatic patellar dislocations with self-reduction and underwent knee arthroscopic surgery with debridement and microfracture of the patella chondral defect, arthroscopic lateral release to improve the patellar tilt, and medial patellofemoral ligament (MPFL) reconstruction. Case 2 is a 15-year-old female who presented with chronic knee pain and patella instability who underwent knee arthroscopic surgery with abrasion arthroplasty, microfracture of the patella, lateral release, tibial tubercle osteotomy medializing osteotomy, and MPFL reconstruction. Case 3 is a 14-year-old male who presented after a single episode of lateral patella dislocation and underwent open reduction and fixation of the lateral femoral condyle osteochondral fracture, a Grammont patellar medialization procedure, and MPFL reconstruction. All three patients received postoperative physical therapy (PT) to improve function and outcomes. These cases represent important concepts of patellar containment, risk factors for recurrent instability, associated pathology, and appropriate surgical care and postoperative rehabilitation. Furthermore, this case series highlights management decisions and pathways for three patients with different symptoms related to patellar instability, subsequent surgical correction, and postoperative physical therapy. Overall, interdisciplinary care of common pediatric orthopedic conditions can help improve patient outcomes and satisfaction. By understanding the biomechanics and decision-making surgical parameters regarding patellofemoral instability, clinicians can provide patients with better care.

Disparities in Pediatric Orthopedic Surgery Care During the COVID-19 Pandemic Pre-vaccine and Post-Vaccine Availability.

BACKGROUND: The COVID-19 pandemic has led to significant disruptions in medical care, resulting in an estimated 40% of US adults avoiding care. However, the return to baseline health care utilization following COVID-19 restrictions within the pediatric orthopedic population remains unexplored. We sought to analyze the visit volume and demographics of pediatric orthopedic patients at 3 timepoints: prepandemic (2019), pandemic (2020), and pandemic post-vaccine availability (2021), to determine the impact of COVID-19 restrictions on our single-center, multisite institution. METHODS: We performed a retrospective cohort study of 6318 patients seeking treatment at our institution from May through August in 2019, 2020, and 2021. Patient age, sex, address, encounter date, and ICD-10 codes were obtained. Diagnoses were classified into fractures and dislocations, non-fracture-related trauma, sports, elective, and other categories. Geospatial analysis comparing incidence and geospatial distribution of diagnoses across the time periods was performed and compared with the Centers for Disease Control (CDC) social vulnerability index (SVI). RESULTS: The total number of pediatric orthopedic visits decreased by 22.2% during the pandemic ( P <0.001) and remained 11.6% lower post-vaccine availability compared with prepandemic numbers ( P <0.001). There was no significant difference in age ( P =0.097) or sex ( P =0.248) of the patients across all 3 timepoints; however, patients seen during the pandemic were more often White race (67.7% vs. 59.3%, P <0.001). Post-vaccine availability, trauma visits increased by 18.2% ( P <0.001) and total fractures remained 13.4% lower than prepandemic volume ( P <0.001). Sports volume decreased during the pandemic but returned to prepandemic volume in the post-vaccine availability period ( P =0.298). Elective visits did not recover to prepandemic volume and remained 13.0% lower compared with baseline ( P <0.001). Geospatial analysis of patient distribution illustrated neighborhood trends in access to care during the COVID-19 pandemic, with fewer patients from high SVI and low socioeconomic status neighborhoods seeking fracture care during the pandemic than prepandemic. Post-vaccine availability, fracture population distribution resembled prepandemic levels, suggesting a return to baseline health care utilization. CONCLUSION: Pediatric orthopedic surgery visit volume broadly decreased during the COVID-19 pandemic and did not return to prepandemic levels. All categories increased in the post-vaccine availability time point except elective visits. Geospatial analysis revealed that neighborhoods with a high social vulnerability index (SVI) were associated with decreased fracture visits during the pandemic, whereas low SVI neighborhoods did not experience as much of a decline. Future research is needed to study these neighborhood trends and more completely characterize factors preventing equitable access to care in the pediatric orthopedic population. LEVEL OF EVIDENCE: Retrospective Study, Level III.

Providence Bracing: Predicting the Progression to Surgery in Patients With Braced Idiopathic Scoliosis.

BACKGROUND: Idiopathic scoliosis (IS) is a common spinal abnormality, in which orthotic management can reduce progression to surgery. However, predictors of bracing success are still not fully understood. We studied a large patient population treated with the nighttime Providence orthosis, utilizing multivariable logistic regression to assess results and predict future spine surgery. METHODS: We retrospectively reviewed patients with IS meeting Scoliosis Research Society inclusion and assessment criteria presenting from April 1994 to June 2020 at a single institution and treated with a Providence orthosis. A predictive logistic regression model was developed utilizing the following candidate features: age, sex, body mass index, Risser classification, Lenke classification, curve magnitude at brace initiation, percentage correction in a brace, and total months of brace use. Model performance was assessed using the area under the receiver operating characteristic curve, accuracy, sensitivity, and specificity. The importance of individual features was assessed using the variable importance score. RESULTS: There were 329 consecutive patients with IS with a mean age of 12.8 ± 1.4 years that met inclusion and assessment criteria. Of these, 113 patients (34%) ultimately required surgery. The model's area under the curve (AUC) was 0.72 on the testing set, demonstrating good discrimination. The initial curve magnitude (Importance score: 100.0) and duration of bracing (Importance score: 82.4) were the 2 most predictive features for curve progression leading to surgery. With respect to skeletal maturity, Risser 1 (Importance score: 53.9) had the most predictive importance for future surgery. For the curve pattern, Lenke 6 (Importance score: 52.0) had the most predictive importance for future surgery. CONCLUSION: Out of 329 patients with IS treated with a Providence nighttime orthosis, 34% required surgery. This is similar to the findings of the BrAist study of the Boston orthosis, in which 28% of monitored braced patients required surgery. In addition, we found that predictive logistic regression can evaluate the likelihood of future spine surgery in patients treated with the Providence orthosis. The severity of the initial curve magnitude and total months of bracing were the 2 most important variables when assessing the probability of future surgery. Surgeons can use this model to counsel families on the potential benefits of bracing and risk factors for curve progression.

Seven-year Outcomes of Adolescent Forearm Fractures Treated With Plate Fixation.

BACKGROUND: Pediatric forearm fractures are common injuries and can sometimes require surgical treatment. Few studies have evaluated the long-term outcomes of pediatric forearm fracture plating. We evaluated long-term functional outcomes and satisfaction in children with forearm fractures treated with plate fixation. METHODS: We performed a single-institution case series at a pediatric level 1 trauma center. Inclusion criteria were: patients with radius and/or ulna diaphyseal fractures, index surgery at 18 years of age or younger, plate fixation, and a minimum of 2 years follow-up. We surveyed patients with the QuickDASH outcome measure and supplemented this with functional outcomes and satisfaction questions. Demographics and surgery characteristics were obtained from the electronic medical record. RESULTS: A total of 41 patients met the eligibility criteria, of whom 17 completed the survey with a mean follow-up of 7.2 ± 1.4 years. The mean age at index surgery was 13.1 ± 3.6 years (range, 4 to 17), with 65% males. All patients reported at least one symptom, with aching (41%) and pain (35%) occurring most frequently. There were 2 complications (12%), including one infection and one compartment syndrome treated with fasciotomy. Hardware removal occurred in 29% of patients. There were no refractures. The mean QuickDASH score was 7.7 ± 11.9, with an occupation module score of 1.6 ± 3.9 and a sports/performing arts module score of 12.0 ± 19.7. The mean surgery satisfaction was 92% and scar satisfaction was 75%. All patients returned to prior activities and 88% reported a return to their preoperative baseline level of function. CONCLUSIONS: Plate fixation for pediatric forearm fractures achieves osseous union but not without the potential for long-term sequelae. All patients reported residual symptoms 7 years later. Scar satisfaction and return to baseline function were imperfect. Patient education for long-term outcomes of surgery is essential, especially in the transition to adulthood. LEVEL OF EVIDENCE: Level IV, therapeutic study.

Surgical Level Selection in Adolescent Idiopathic Scoliosis: An Evidence-Based Approach.

The selection of fusion levels in the treatment of adolescent idiopathic scoliosis remains complex. The goals of surgery are to minimize the risk of future progression and optimize spinal balance while fusing the least number of levels necessary. Several classifications, rules, and algorithms exist to guide decision making, although these have previously not been easily referenced in a study. This review aims to provide an evidence-based approach of selecting fusion levels that balances the expert opinion of the authors with the current literature.

Sensitivity and Specificity of MRI in Diagnosing Concomitant Meniscal Injuries With Pediatric and Adolescent Acute ACL Tears.

Background: Preoperative diagnosis of concomitant meniscal tears in pediatric and adolescent patients with acute anterior cruciate ligament (ACL) deficiency is challenging. Purpose: To investigate the diagnostic performance of magnetic resonance imaging (MRI) in detecting meniscal injuries for pediatric and adolescent patients with acute ACL tears. Study Design: Cohort study (diagnosis); Level of evidence, 2. Methods: The authors retrospectively identified patients aged ≤18 years who underwent acute ACL reconstruction between 2006 and 2018 at 2 tertiary academic hospitals. The primary outcomes were arthroscopically confirmed medial, lateral, or any (defined as medial and/or lateral) meniscal tears. To control for chronically deficient knees, patients must have received their MRI study within 4 weeks of injury and must have undergone surgery no more than 8 weeks after their MRI study. Preoperative MRI reports were compared with the gold standard of arthroscopically confirmed tears to calculate sensitivity, specificity, positive predictive value, and negative predictive value. In a secondary analysis, patients were stratified by age into 2 groups (≤13 or ≥14 years), body mass index-for-age data from the Centers for Disease Control were used to classify patients as obese or nonobese, and differences between sensitivity and specificity proportions were analyzed using chi-square test for homogeneity. Results: Overall, 406 patients with a mean age of 15.4 years (range, 10-18 years) were identified. The sensitivity, specificity, positive predictive value, and negative predictive value were as follows: for lateral meniscal (LM) tears, 51.0%, 86.5%, 78.3%, and 65.0%; for medial meniscal tears, 83.2%, 80.6%, 62.3%, and 92.5%; and for any meniscal tear, 75.0%, 72.1%, 81.5%, and 63.8%, respectively. In the stratified analysis, MRI was less specific for the following diagnoses: any meniscal tear in patients aged ≤13 years (P = .048) and LM tears in obese patients (P = .020). Conclusion: The diagnostic ability of MRI to predict meniscal injuries present at acute ACL reconstruction was moderate. Performance was poorest at the lateral meniscus, where MRI failed to detect 97 tears that were found arthroscopically. Specificity was significantly lower in younger patients for any meniscal tear and in obese patients for LM tears.

What Are the Causes and Consequences of Delayed Surgery for Pediatric Tibial Spine Fractures? A Multicenter Study.

Background: The uncommon nature of tibial spine fractures (TSFs) may result in delayed diagnosis and treatment. The outcomes of delayed surgery are unknown. Purpose: To evaluate risk factors for, and outcomes of, delayed surgical treatment of pediatric TSFs. Study Design: Cohort study; Level of evidence, 3. Methods: The authors performed a retrospective cohort study of TSFs treated surgically at 10 institutions between 2000 and 2019. Patient characteristics and preoperative data were collected, as were intraoperative information and postoperative complications. Surgery ≥21 days after injury was considered delayed based on visualized trends in the data. Univariate analysis was followed by purposeful entry multivariate regression to adjust for confounders. Results: A total of 368 patients (mean age, 11.7 ± 2.9 years) were included, 21.2% of whom underwent surgery ≥21 days after injury. Patients who experienced delayed surgery had 3.8 times higher odds of being diagnosed with a TSF at ≥1 weeks after injury (95% CI, 1.1-14.3; P = .04), 2.1 times higher odds of having seen multiple clinicians before the treating surgeon (95% CI, 1.1-4.1; P = .03), 5.8 times higher odds of having magnetic resonance imaging (MRI) ≥1 weeks after injury (95% CI, 1.6-20.8; P < .007), and were 2.2 times more likely to have public insurance (95% CI, 1.3-3.9; P = .005). Meniscal injuries were encountered intraoperatively in 42.3% of patients with delayed surgery versus 21.0% of patients treated without delay (P < .001), resulting in 2.8 times higher odds in multivariate analysis (95% CI, 1.6-5.0; P < .001). Delayed surgery was also a risk factor for procedure duration >2.5 hours (odds ratio, 3.3; 95% CI, 1.4-7.9; P = .006). Patients who experienced delayed surgery and also had an operation >2.5 hours had 3.7 times higher odds of developing arthrofibrosis (95% CI, 1.1-12.5; P = .03). Conclusion: Patients who underwent delayed surgery for TSFs were found to have a higher rate of concomitant meniscal injury, longer procedure duration, and more postoperative arthrofibrosis when the surgery length was >2.5 hours. Those who experienced delays in diagnosis or MRI, saw multiple clinicians, and had public insurance were more likely to have a delay to surgery.

A Multicenter Comparison of Open Versus Arthroscopic Fixation for Pediatric Tibial Spine Fractures.

BACKGROUND: When operative treatment is indicated, tibial spine fractures can be successfully managed with open or arthroscopic reduction and internal fixation (ARIF). The purpose of the study is to evaluate short-term treatment outcomes of tibial spine fractures in patients treated with both open and arthroscopic fracture reduction. METHODS: We performed an Institutional Review Board (IRB)-approved retrospective cohort study of pediatric tibial spine fractures presenting between January 1, 2000 and January 31, 2019 at 10 institutions. Patients were categorized into 2 cohorts based on treatment: ARIF and open reduction and internal fixation (ORIF). Short-term surgical outcomes, the incidence of concomitant injuries, and surgeon demographics were compared between groups. RESULTS: There were 477 patients with tibial spine fractures who met inclusion criteria, 420 of whom (88.1%) were treated with ARIF, while 57 (11.9%) were treated with ORIF. Average follow-up was 1.12 years. Patients treated with ARIF were more likely to have an identified concomitant injury (41.4%) compared with those treated with ORIF (24.6%, P=0.021). Most concomitant injuries (74.5%) were treated with intervention. The most common treatment complications included arthrofibrosis (6.9% in ARIF patients, 7.0% in ORIF patients, P=1.00) and subsequent anterior cruciate ligament injury (2.1% in ARIF patients and 3.5% in ORIF, P=0.86). The rate of short-term complications, return to the operating room, and failure to return to full range of motion were similar between treatment groups. Twenty surgeons with sports subspecialty training completed 85.0% of ARIF cases; the remaining 15.0% were performed by 12 surgeons without additional sports training. The majority (56.1%) of ORIF cases were completed by 14 surgeons without sports subspecialty training. CONCLUSION: This study demonstrated no difference in outcomes or nonunion following ARIF or ORIF, with a significantly higher rate of concomitant injuries identified in patients treated with ARIF. The majority of identified concomitant injuries were treated with surgical intervention. Extensive surgical evaluation or pretreatment magnetic resonance imaging should be considered in the workup of tibial spine fractures to increase concomitant injury identification. LEVEL OF EVIDENCE: Level III.

Surgical site infections in early onset scoliosis: what are long-term outcomes in patients with traditional growing rods?

PURPOSE: Deep surgical site infections (SSIs) are a common and potentially severe complication in early onset scoliosis (EOS) patients. We sought to identify the long-term outcomes following SSI, specific risk factors associated with recurrent infections, and if instrument retention is a prudent SSI management strategy in EOS. METHODS: We performed a retrospective review of all EOS patients who underwent traditional growing rod spine procedures from 2003 to 2017. Infections were categorized as single or multiple SSIs. All infections were treated with operative irrigation and debridement (I&D) as well as antibiotics. Univariate analysis was performed using chi-square and ANOVA tests to assess differing factors between patients with single versus multiple infections. RESULTS: Eighty-one patients underwent 638 growth-friendly traditional growing rod procedures. There were 21 patients (26%) who developed a total of 27 SSIs (4.2% SSI per procedure). Fifteen patients had a single infection and six patients had multiple infections. Demographics were not significantly different between these two groups. Patients with multiple infections had a significant difference in the number of procedures after initial infection (p value = 0.025) and positive preoperative nasal Staphylococcus aureus screen (p value = 0.0021) when compared to those with a single SSI. Of note, these results were not available at the time of pre-operative antibiotic selection. All 21 patients had resolution of their SSIs. Twenty patients reached final instrumented fusion. Two patients, both of whom had multiple infections, underwent complete removal of instrumentation. Reasons included one each, parental request resulting in termination of treatment and infection > 7 years after final fusion. CONCLUSION: Most patients who develop SSIs during growing spine treatment are able to remain instrumented. Risk factors associated with developing multiple SSIs include infection earlier in the course of growing spine surgery, a resultant higher number of procedures following the initial infection and having a positive preoperative nasal Staphylococcus aureus screen. LEVEL OF EVIDENCE: IV.

Proximal junctional kyphosis in pediatric spinal deformity surgery: a systematic review and critical analysis.

PURPOSE: Proximal junctional kyphosis (PJK) is a commonly encountered clinical and radiographic phenomenon after pediatric and adolescent spinal deformity surgery that may lead to post-operative deformity, pain, and dissatisfaction. Understanding the risk factors of PJK can be useful for pre-operative informed consent as well as to identify any potential preventative strategies. METHODS: We performed a systematic review and critical analysis following the PRISMA statement in July 2019 by searching the PubMed, Scopus, and Embase databases, including all prior published studies. We included articles with data on PJK in patients with operative pediatric and adolescent scoliosis and those that detailed risk factors and/or preventative strategies for PJK. Levels of evidence were determined based on consensus. Findings were summarized and grades of recommendation were assigned by consensus. This study was registered in the PROSPERO database; 202,457. RESULTS: Six hundred and thirty five studies were identified. Thirty-seven studies met criteria for inclusion into the analysis. No studies including neuromuscular scoliosis met inclusion criteria. No findings had Grade A evidence. There were 4 findings found to contribute to PJK with Grade B evidence in EOS: higher number of distractions, disruption of posterior elements, greater sagittal plane correction. There was no difference in incidence noted between etiology of the curvature. Five findings with Grade B evidence were found to contribute to PJK in AIS populations: higher pre-operative thoracic kyphosis, higher pre-operative lumbar lordosis, longer fusion constructs, greater sagittal plane correction, and posterior versus anterior fusion constructs. CONCLUSION: Greater sagittal plane correction has Grade B evidence as a risk factor for PJK in both EOS and AIS populations. In EOS patients, an increased number of distractions and posterior element disruption are Grade B risk factors. In AIS patients, longer fusion constructs, higher pre-operative thoracic kyphosis and lumbar lordosis, and posterior (as opposed to anterior) constructs also contributed to PJK with Grade B evidence. These findings can guide informed consent and surgical management, and provide the foundation for future studies.

Does Insurance Status Affect Treatment of Children With Tibial Spine Fractures?

BACKGROUND: Previous studies have reported disparities in orthopaedic care resulting from demographic factors, including insurance status. However, the effect of insurance on pediatric tibial spine fractures (TSFs), an uncommon but significant injury, is unknown. PURPOSE: To assess the effect of insurance status on the evaluation and treatment of TSFs in children and adolescents. STUDY DESIGN: Cross-sectional study; Level of evidence, 3. METHODS: We performed a retrospective cohort study of TSFs treated at 10 institutions between 2000 and 2019. Demographic data were collected, as was information regarding pre-, intra-, and postoperative treatment, with attention to delays in management and differences in care. Surgical and nonsurgical fractures were included, but a separate analysis of surgical patients was performed. Univariate analysis was followed by purposeful entry multivariate regression to adjust for confounding factors. RESULTS: Data were collected on 434 patients (mean ± SD age, 11.7 ± 3.0 years) of which 61.1% had private (commercial) insurance. Magnetic resonance imaging (MRI) was obtained at similar rates for children with public and private insurance (41.4% vs 41.9%, respectively; P≥ .999). However, multivariate analysis revealed that those with MRI performed ≥21 days after injury were 5.3 times more likely to have public insurance (95% CI, 1.3-21.7; P = .02). Of the 434 patients included, 365 required surgery. Similar to the overall cohort, those in the surgical subgroup with MRI ≥21 days from injury were 4.8 times more likely to have public insurance (95% CI, 1.2-19.6; P = .03). Children who underwent surgery ≥21 days after injury were 2.5 times more likely to have public insurance (95% CI, 1.1-6.1; P = .04). However, there were no differences in the nature of the surgery or findings at surgery. Those who were publicly insured were 4.1 times more likely to be immobilized in a cast rather than a brace postoperatively (95% CI, 2.3-7.4; P < .001). CONCLUSION: Children with public insurance and a TSF were more likely to experience delays with MRI and surgical treatment than those with private insurance. However, there were no differences in the nature of the surgery or findings at surgery. Additionally, patients with public insurance were more likely to undergo postoperative casting rather than bracing.

Postoperative Correction in Idiopathic Scoliosis: Which Preoperative Imaging Technique Is Most Predictive?

INTRODUCTION: Preoperative radiographic assessment of curve flexibility in patients with idiopathic scoliosis is important to determine Lenke classification, operative levels, and potential postoperative correction. However, no consensus exists regarding the optimal technique. We compared measurements from supine side bending (SB) and intraoperative traction radiographs under general anesthesia (TUGA) with actual postoperative correction followed for 1 year. METHODS: We identified 235 patients with idiopathic scoliosis who underwent posterior spinal fusion with pedicle screw instrumentation between 2010 and 2018 who had preoperative and postoperative radiographs including standing posterior-anterior (PA) and lateral radiographs, preoperative SB radiographs, and TUGA radiographs. Curves were categorized into proximal thoracic, main thoracic/thoracolumbar (MT), and distal thoracolumbar/lumbar (TL/L) curves. Flexibility was calculated from SB and TUGA radiographs. Correction rates were calculated from 1 month and 1 year radiographs postoperatively. Bending radiographs that correlated significantly with postoperative correction with P<0.10 were eligible for inclusion. Preoperative demographics, etiology, deformity details, and surgical details were included in the multivariate models. RESULTS: On univariate analysis, TUGA radiographs correlated with postoperative correction at 1 month and 1 year on MT curves (r=0.214, P=0.001; r=0.209, P=0.001) and TL/L curves (r=0.280, P<0.001; r=0.181, P=0.006). Supine SB radiographs did not correlate with postoperative correction on either MT or T/TL curves. On multivariate analysis, major curve TUGA radiographs were independently associated with postoperative MT curve correction at 1 month (beta: 0.158, 95% confidence interval: 0.035-0.280, P=0.012) and 1 year (beta: 0.195, 95% confidence interval: 0.049-0.340, P=0.009). MT curve SB radiographs were not associated with postoperative major curve correction at 1 month (P=0.088). CONCLUSIONS: TUGA radiographs independently correlated with postoperative main thoracic and distal thoracolumbar/lumbar curve correction at 1 month and 1 year postoperatively. SB radiographs independently correlated only with TL/L curve correction at 1 year postoperatively. However, this correlation was not as strong as TUGA correction (beta of 0.280 vs. beta of 0.092). TUGA radiographs appear superior to SB radiographs at predicting curve correction after surgery. LEVEL OF EVIDENCE: Level III.

Cell-free stem cell-derived extract formulation for treatment of knee osteoarthritis: study protocol for a preliminary non-randomized, open-label, multi-center feasibility and safety study.

BACKGROUND: Musculoskeletal conditions are highly prevalent, and knee OA is most common. Current treatment modalities have limitations and either fail to solve the underlying pathophysiology or are highly invasive. To address these limitations, attention has focused on the use of biologics. The efficacy of these devices is attributed to presence of growth factors (GFs), cytokines (CKs), and extracellular vesicles (EVs). With this in mind, we formulated a novel cell-free stem cell-derived extract (CCM) from human progenitor endothelial stem cells (hPESCs). A preliminary study demonstrated the presence of essential components of regenerative medicine, namely GFs, CKs, and EVs, including exosomes, in CCM. The proposed study aims to evaluate the safety and efficacy of intraarticular injection of the novel cell-free stem cell-derived extract (CCM) for the treatment of knee OA. METHODS AND ANALYSIS: This is a non-randomized, open-label, multi-center, prospective study in which the safety and efficacy of intraarticular CCM in patients suffering from grade II/III knee OA will be evaluated. Up to 20 patients with grade II/III OA who meet the inclusion and exclusion criteria will be consented and screened to recruit 12 patients to receive treatment. The study will be conducted at up to 2 sites within the USA, and the 12 participants will be followed for 24 months. The study participants will be monitored for adverse reactions and assessed using Numeric Pain Rating Scale (NPRS), Patient-Reported Outcomes Measurement Information System (PROMIS) Score, Knee Injury and Osteoarthritis Outcome Score Jr. (KOOS Jr.), 36-ietm short form survey (SF-36), Single Assessment Numeric Evaluation (SANE), physical exams, plain radiography, and magnetic resonance imaging (MRI) with Magnetic Resonance Observation of Cartilage Repair Tissue (MOCART) score for improvements in pain, function, satisfaction, and cartilage regeneration. DISCUSSION: This prospective study will provide valuable information into the safety and efficacy of intraarticular administration of cell-free stem cell-derived extract (CCM) in patients suffering with grade II/III knee OA. The outcomes from this initial study of novel CCM will lay the foundation for a larger randomized, placebo-controlled, multi-center clinical trial of intraarticular CCM for symptomatic knee OA. TRIAL REGISTRATION: Registered on July 21, 2021. ClinicalTrials.gov NCT04971798.

ACL Reconstruction Delay in Pediatric and Adolescent Patients Is Associated with a Progressive Increased Risk of Medial Meniscal Tears.

BACKGROUND: We sought to investigate the relationship between the time from an anterior cruciate ligament (ACL) tear to the surgical procedure and meniscal tears in the pediatric and adolescent population. METHODS: Patients who were ≤18 years of age and had undergone an ACL reconstruction from 2006 to 2018 were identified in a retrospective, multicenter cohort. The primary outcomes were arthroscopically confirmed medial meniscal or lateral meniscal tears specifically and, in general, if any meniscal tear was present (medial and/or lateral). A multivariable Poisson regression model was used to determine whether the time from the injury to the surgical procedure was a risk factor for subsequent meniscal injury, after controlling for sex, age, and body mass index (BMI). Multivariable Poisson regression was also used to characterize associations of age, sex, and BMI with meniscal injury. RESULTS: In this study, 546 patients with a mean age (and standard deviation) of 15.3 ± 1.6 years were identified. For each week that the surgical procedure was delayed, there was a 2% increased risk of a medial meniscal tear (adjusted relative risk [ARR], 1.02 [95% confidence interval (CI), 1.01 to 1.03]). The weekly increase in risk of a medial meniscal injury was significant for male patients (ARR, 1.03 [95% CI, 1.01 to 1.05]), but not for female patients (ARR, 1.00 [95% CI, 0.97 to 1.04]), even though the effect modification was not significant (p = 0.24). Obese male patients had a 77.9% increased risk of medial meniscal tear for each 10-week delay (p < 0.001). The use of crutches was associated with a decreased risk of medial meniscal tears (ARR, 0.47 [95% CI, 0.34 to 0.64]). CONCLUSIONS: In pediatric and adolescent patients, the risk of meniscal injury is substantial after an ACL tear. A delay from the injury to the surgical procedure was associated with a 3% weekly increased risk of medial meniscal injury for male patients, but not for female patients. The increased risk of medial meniscal injury with delays to the surgical procedure was particularly high for obese male patients. LEVEL OF EVIDENCE: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

A Comparison of Nonoperative and Operative Treatment of Type 2 Tibial Spine Fractures.

BACKGROUND: Tibial spine fractures (TSFs) are typically treated nonoperatively when nondisplaced and operatively when completely displaced. However, it is unclear whether displaced but hinged (type 2) TSFs should be treated operatively or nonoperatively. PURPOSE: To compare operative versus nonoperative treatment of type 2 TSFs in terms of overall complication rate, ligamentous laxity, knee range of motion, and rate of subsequent operation. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: We reviewed 164 type 2 TSFs in patients aged 6 to 16 years treated between January 1, 2000, and January 31, 2019. Excluded were patients with previous TSFs, anterior cruciate ligament (ACL) injury, femoral or tibial fractures, or grade 2 or 3 injury of the collateral ligaments or posterior cruciate ligament. Patients were placed according to treatment into the operative group (n = 123) or nonoperative group (n = 41). The only patient characteristic that differed between groups was body mass index (22 [nonoperative] vs 20 [operative]; P = .02). Duration of follow-up was longer in the operative versus the nonoperative group (11 vs 6.9 months). At final follow-up, 74% of all patients had recorded laxity examinations. RESULTS: At final follow-up, the nonoperative group had more ACL laxity than did the operative group (P < .01). Groups did not differ significantly in overall complication rate, reoperation rate, or total range of motion (all, P > .05). The nonoperative group had a higher rate of subsequent new TSFs and ACL injuries requiring surgery (4.9%) when compared with the operative group (0%; P = .01). The operative group had a higher rate of arthrofibrosis (8.9%) than did the nonoperative group (0%; P = .047). Reoperation was most common for hardware removal (14%), lysis of adhesions (6.5%), and manipulation under anesthesia (6.5%). CONCLUSION: Although complication rates were similar between nonoperatively and operatively treated type 2 TSFs, patients treated nonoperatively had higher rates of residual laxity and subsequent tibial spine and ACL surgery, whereas patients treated operatively had a higher rate of arthrofibrosis. These findings should be considered when treating patients with type 2 TSF.

Predicting Risk of Recurrent Patellofemoral Instability With Measurements of Extensor Mechanism Containment.

BACKGROUND: Identifying risk factors for recurrent patellar dislocation after a primary dislocation may help guide initial treatment. Magnetic resonance imaging (MRI) measurements relating the alignment of the extensor mechanism to trochlear morphology have been shown to distinguish patients with dislocations from controls, but their usefulness in predicting the risk of a second dislocation is not known. PURPOSE: To identify the association of novel MRI measures of patellar containment with recurrent instability in pediatric patients presenting with a first-time patellar dislocation. STUDY DESIGN: Cohort study (Prognosis); Level of evidence, 3. METHODS: The study was conducted at a tertiary care children's hospital (2005-2014) on patients (age, 8-19 years) with a first-time patellar dislocation. MRI measurements were made by 2 independent raters. Interobserver reliability was assessed for all measurements via an intraclass correlation coefficient (ICC). Only measurements with an ICC >0.8 were included. Univariable and multivariable logistic regression analyses were used to evaluate variables associated with recurrence. RESULTS: A total of 165 patients with a median age of 14 years and a slight (57.6%) female predominance was identified. The median follow-up length of the whole cohort was 12.2 months (interquartile range, 1.6-37.1 months). Subsequent instability was documented in 98 patients (59.4%). MRI measurements with excellent correlation (ICC > 0.8) were the tibial tubercle to trochlear groove distance (TT-TG), the tangential axial width of the patella, the tangential axial trochlear width, the axial width of the patellar tendon beyond the lateral trochlear ridge (LTR), and the tibial tubercle to LTR distance. In univariate analysis, all mentioned MRI measurements had significant association with recurrent instability. However, after both backward and forward stepwise regression analyses, the tibial tubercle to LTR distance was the only independent predictor of recurrent instability (P = .003 in both). Patients with a tibial tubercle to LTR distance value greater than -1 mm had a significantly higher rate of recurrent patellar dislocation (72%). CONCLUSION: Of numerous axial view MRI parameters, only the tibial tubercle to LTR distance demonstrated a statistically significant association with recurrent patellar instability upon multivariable logistic regression analysis during short-term follow-up of a pediatric population presenting with initial lateral patellar dislocation. Interobserver correlation of the tibial tubercle to LTR distance was good (ICC > 0.8) and similar to that of TT-TG.

Is There Value in Venous Thromboembolism Chemoprophylaxis After Pediatric Scoliosis Surgery? A 28-Year Single Center Study.

BACKGROUND: With a recognized increase in the incidence of venous thromboembolism (VTE) in children, especially in those with complex, chronic conditions, it is important for patient safety and risk management to identify subgroups that would benefit from prophylactic treatment. The aim of our study was to assess whether scoliosis surgery in children was associated with an increased incidence of VTE, including deep venous thrombosis (DVT) and pulmonary embolism, and if chemoprophylaxis is warranted. METHODS: We reviewed our institution's Pediatric Orthopaedic Spine Database (1992-2019) to identify patients who had a symptomatic VTE postoperatively. RESULTS: There were 1471 patients (1035 female, 436 male) with a mean age at surgery of 12.1±3.2 years (range, 1 to 18 y) underwent posterior spinal fusion and instrumentation (2131 procedures). No patients were given pharmacological VTE prophylaxis, and no routine screening for VTE was performed. Two patients had a lower extremity DVT (0.13%) within 6 months following surgery, (range, 55 to 161 d). Neither patient had a subsequent pulmonary embolism. They were 9 and 17 years of age with a diagnosis of neuromuscular scoliosis (1 each postpolio and myelodysplasia). One affected patient had a central venous line inserted perioperatively, a known risk factor for thromboembolism. All DVTs were treated with appropriately dosed anticoagulants. None had a family history of hypercoagulation. CONCLUSIONS: The risk of symptomatic VTE is extraordinarily low after pediatric spinal deformity surgery. Mechanical prophylaxis is sufficient in most cases. Further multi-center studies may help identify patient specific risk factors.